Attachment 3 -Contractor EMR Certification Form.pdf
PDF 89 KB Posted
- Solicitation number
- 36C25021B0012
About this file
This document contains a federal contract solicitation and related contractor evaluation form. The solicitation is for repair and construction services at the Cincinnati VA Medical Center, including repairing exterior walls and replacing windows in Building B1. The estimated value of the contract is between $5 million and $10 million. The solicitation number is 36C25021B0012 and will be posted on January 14, 2021, with bids due within 30-45 days thereafter. The contractor will have 550 days from notice to proceed to complete all work. This solicitation is set aside for service-disabled veteran-owned small businesses. The related contractor evaluation form requests safety and insurance information from contractors, including OSHA recordable incident rates and insurance modification rates.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25021B0012 0008.docx | DOCX document | |
| Addendum 08-04.14.21.pdf | ||
| 36C25021B0012 0007.docx | DOCX document | |
| Addendum 06-04.05.21.pdf | ||
| 36C25021B0012 0006.pdf | ||
| Addendum 05-03.24.21.pdf | ||
| 36C25021B0012 0005.docx | DOCX document | |
| 36C25021B0012 0004.docx | DOCX document | |
| 36C25021B0012 0003.docx | DOCX document | |
| Site VIsit Sign-in.pdf | ||
| 36C25021B0012 0002.docx | DOCX document | |
| 36C25021B0012 0001.docx | DOCX document | |
| Attachment 4 - EMR Attachment.pdf | ||
| Attachment 2-Drawings.pdf | ||
| Attachment 5-DBA-WD-OH020210082.pdf | ||
| Attachment 1-Specifications.pdf | ||
| 36C25021B0012_1.docx | DOCX document | |
| Attachment 3 - RFI Form.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation #36C25021B0012:
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours)
(DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate
(EMR):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .